Provider Demographics
NPI:1851369409
Name:MID-COLUMBIA MEDICAL CENTER
Entity Type:Organization
Organization Name:MID-COLUMBIA MEDICAL CENTER
Other - Org Name:ADVENTIST HEALTH COLUMBIA GORGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE OFFICER CEO
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-296-7273
Mailing Address - Street 1:1700 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3317
Mailing Address - Country:US
Mailing Address - Phone:541-296-7760
Mailing Address - Fax:541-296-7619
Practice Address - Street 1:1700 E 19TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3317
Practice Address - Country:US
Practice Address - Phone:541-296-7760
Practice Address - Fax:541-296-7619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14 0500273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2005186Medicaid
OR026484Medicaid
OR026484Medicaid